Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, December 29, 2006

Memorable Patients: part seven

I first met her when I consulted on her hospitalized son, who'd been in and out several times with transient abdominal pain. He'd already been through various tests and consultations, each time improving before a diagnosis was established. When I was asked to see him he was once again on the mend, but I concluded that he likely had the uncommon condition of recurrent appendicitis, and proposed surgery. Taking out his appendix, which I did shortly thereafter, permanently cured him, and the pathologist confirmed the diagnosis. Mrs. Davidson told me she knew God had sent me to them, and thanked me prayerfully. As her son recovered, she prayed with him as well.

When next we met a few years later, she was the patient, having discovered a lump in her breast. With a fine-needle aspiration I confirmed the diagnosis of cancer, and before long we were together in the operating room. Based on my physical exam, I expected to find some lymph nodes containing tumor; but when I got into her axilla, I was surprised -- sickened, really -- by how many. There's a clear correlation between failure to cure and the number of lymph nodes under the arm. Whether removing those nodes is therapeutic or merely diagnostic is a matter of disagreement: in other words, does removing them improve prognosis in any way other than telling us what we're up against? Regardless of further therapy, is it good to remove all the nodes you can? I think so, until clearly shown to be otherwise. When the cancer has marched its way all through the axilla, the odds are very strong that it's gone beyond as well; but in the absence of proof of spread outside the axilla, it's still theoretically possible that removing all the tumor in the breast and under the arm will be curative. Theoretically. That's what I did for Mrs. Davidson, and of the fifty or so lymph nodes found in the tissues I dissected out, thirty-two had tumor in them. I think that's the record, in my practice. Her risk of relapse somewhere in her body was dauntingly high.

At each stage of the game, Mrs. Davidson prayed, and her faith seemed to carry her. The lump would be OK, she felt, and when it wasn't she knew God would be with her. But when she got the news about the lymph nodes, and the implication for cure, and when she heard the recommendation of her oncologist, she fell apart.

Not far down the road from my area of practice, there was an on-going study of women with advanced breast cancer: removing and preserving bone-marrow stem cells, giving massive doses of chemotherapy and radiation -- enough permanently to kill the production capabilities of the marrow -- followed by returning to the patient her saved marrow cells to regrow her blood-making ability. It was tough stuff, taking the women to the brink in a most literal sense, suitable -- if at all -- only for those with very poor prospects. (The therapy has fallen into disrepute, in a pretty messy set of circumstances featuring another patient of mine who'd come to me with widespread recurrence.) With cancer all over the body, it was a desperate "hail Mary" of a treatment. In a situation like Mrs. Davidson's, it made more sense, at least from some points of view: take a woman with a very high statistical chance of having cancer somewhere, but undetectable, in her body, throw the therapeutic book at her on the theory that the best chance to cure lay in getting those cells when they were at their fewest in number. (Which is also part of the rationale of removing all the involved nodes.) That's what her oncologist recommended, and I concurred.

For Mrs. Davidson, it was hell on earth. Unable to eat, nauseated, dependent entirely on intravenous feedings, bleeding what little blood she had, fighting infections -- she was as miserable as it gets. Per protocol, she remained hospitalized for the entire treatment and well after the stem-cell reinfusion. Her husband, who worked at a coffee shop I frequented, told me on many occasions that she'd said she wanted to die, that she'd begged them to stop treatment. He wouldn't let her; he wanted her around. But she sank deeper and deeper into depression; how could God do this to her, she asked, after everything she'd done for God?

Her anger and depression outlasted her therapy. After her release from the hospital, I saw her fairly regularly, even though she'd healed her surgery: she just wanted to come in and ventilate. As hard as it was for her, it was frustrating for me: surgeons like to fix things, and I had little to offer except an ear. Seeing her continuing to lose weight, to descend into darkness, I finally suggested anti-depressants, which she accepted with a "why-bother" shrug. In the periods between visits, which eventually tapered off, I frequently saw her husband at the coffee-shop. He was nearing the end of his rope as well. She remained despondent, he said, despite the passage of time with no sign of cancer.

I've generally observed that when people have deep religious faith of any sort, in most cases it helps them cope with bad news: "God's will." Despite her attitude when I cared for her son, in Mrs. Davidson's own crisis it seems to have done the opposite. Funny thing is it's over fifteen years since all this happened, and she's doing great. Her depression is long gone, she's active, and there's not been any evidence of disease since her operation. In our relationship, I never initiated discussion of her faith, and I don't know where it ended up in her life. In medicine, nothing is 100%. She seems to have beaten very long odds. How? Maybe I actually got to her at the moment before any distant spread, and my operation cured her. Maybe the hyper-intense therapy did exactly what it was intended to do. Maybe she'll recur still, and we just bought her some time. Or maybe....

14 comments:

My trauma surgeon of 16 years ago (I had the ventriculostomy) may have harbored the same concern for me as you did for your memorable patient. My husband and I moved across country a year after my car accident, and though I had been paralyzed at one point (I had to learn to do everything again) I never had any physical therapy. I remember after I woke up from my coma and for a while afterward, forcing my limbs to move with my mind but not being able to budge in reality. I’ve learned that people usually recover from a brain injury as much as they’re going to by 1 - 3 years, and I think I had much of the basics back by then, but the psychological ramifications, including my depression and confusion, didn’t even begin to ease up for at least ten years, and especially not until I learned to laugh again. I had reoccurring nightmares of a knife-wielding serial killer until just a few years ago, which was my injured mind’s interpretation of surgery, nightmares that I know exorcized the trauma from my mind. I think you provided an essential part of surgical care for your memorable patient by listening to her. By listening, one can gracefully and dramatically cut to the core of an emotional need. A person’s soul needs a surgeon as much as the body does. I write my trauma surgeon from that accident because I’m in college as a gift to him, from the bottom of my heart, though greater is the gift he’s giving me by receiving my letters. Sometimes I talk about what my surgery, my coma, and my recovery were like. He’s cut away the worst my emotional trauma, as you did for your memorable patient by listening to her in the worst of her struggle (and that cutting away in itself has been a religious experience).

my best girlfriend had the stem cell transplant in jacksonville in 1995. she was stage four before any treatment. she is alive and well today and free of cancer. we went to europe two years ago together. i don't think they do that any more do they? she says her dr. (joyce) and god cured her. thanks for the article. bee

or maybe it was a miracle? That God did his work through the hands of her doctors?

Is this cosmic symmetry to balance those seemingly "simple" cases that go unexpectedly wrong?

I hope that the woman was able to come to terms with her experience and to reconcile the seemingly "abandonment" by God or that she was able to see God in a form that wasn't immediately recognized.

I also want to reinforce the idea that happyj said...that post-surgical healing can be as simple as having a compassionate listener. I also find it fascinating that her life saving surgeon in real life, morphed into a knife welding serial killer in her dreams. I think that is part of the cognitive dissonance that the trauma of surgery causes: that what the brain recognizes as life saving actions is emotionally interpreted as a violent attack on personal security and well being. Maybe talking it out allows us to bring those conflicts into some resolution (?)

Maybe that is why there is such a love-hate relationship between surgeons and patients at times.

Thanks for taking the extra time to listen to your patient, even though frustrating for you. It's amazing what a difference it makes in a patient's life to have a physician that listens; often those small tidbits of wisdom that you pass along give them hope.

God refines us by holding us over the flame. It is only then, in the fire pit, can we truely evolve into the person he wants us to be. Sometimes by almost dying, it saves you. Sometimes you have to lose everything to gain everything. Being sick like that is blessing. You just have to step back long enought o see it. You did a good thing by letting her vent to you. That helps heal the torn and tortuned soul of one so sick. It's part of the healing process. The physcial stuff is pretty easy in comparison. I am glad she had recovered.

I’ve seen this before. Sometimes their faith is rattled. They feel if G_d loved them, then no harm would come to them. Being in the world, we aren’t promised that. It would be great if someone could say to them, Oh but he didn’t abandon you; he saw to it you had the best surgeons, doctors, nurses, ambulance crew, all right there ready to help you. That is not being forsaken in time of trouble. Trouble comes; we live in a fallen world, but he is faithful to seeing us through whatever traumas we have to endure.

i think of the times i felt God had let me down. during those times, i also became very depressed. but upon reflection, i see that the source of the 'failure' is always me. this isnt bad news, or self condemnation. this is good news, because i can change me.

i have learned, from reading His word and walking with Him these 27 years, that God always does His part, without fail. it is my responsibility to believe and receive even in the face of apparent failure. often i have been told by well meaning people that it was God's will for me to suffer this or that. but if that were true, He would not have told me how to overcome it, and given me the means to do just that.

God had made some very specific promises to His children, all of which are guarenteed in ll cor 1:20. what he has promised us, capulated, is the armour and weaponry to overcome ever thing slung at us in this fallen world. and help in learning to use them. and when we fall short of victory, He has promised to be there to pick us up and carry us thru, if we will trust Him even in the pitch darkness of our own confusion.

as chrysalis angel so aptly put it, we do live in a fallen world. we are in enemy territory, as it were. God hasnt promised us we would live a pain free, unchallenged life. He has promised us and equiped us for winning the battles.

Wow! Dr Schwab, you and the other comments have profoundly spoken to me.

A year ago tonight,(New Year's Day - nite)I presented to a hospital with sepsis, pyelonephritis and hydronephrosis. I had no idea what was brewing and went to work New Year's Eve thinking I had a UTI and the Doc would fix me up and he did give me meds.

Turns out my ureter was totally blocked, which was initially caused by scarring from a large kidney stone a couple of years earlier. The Urologist was able to open the block at the time and has done several procedures to facilitate my healing. Things were looking good but it appears it may be closing off again. I may have to have a Boari Flap/Psoas hitch surgery to correct it and I am still in the information gathering process. The whole idea of a 3 hr surgery (anesthesia) and possibility of complications has totally unnerved me. I know I have been blessed to have this urologist handling my case. He is so busy but has ALWAYS listened to me. He is cutting edge and is on top of everything, which has helped me to feel more secure.

Having said all of that, I am also unnerved that he wants me to go to another surgeon (still trying to figure out who and where, and he is helping me with that) because he wants me to be in a hospital where there are doctors in the hospital 24/7 because I am not a good candidate for the surgery and there could be complications and the post-op period is extremely important. Also, that while he has done the surgery, he wants me to go to someone who does it more often. I know it is important for a doctor to know their limitations and I greatly respect him for that.

I in no way pretend that my health issues compare to the other things posted here. I appreciate the posts and sharing people have done,giving me further insight.

Your patient was blessed to have you listen like you did. Obviously you were very busy and would've preferred doing something you knew you could fix, yet by listening, you very well may have helped to save her life a second time.

Think Jimmy Stewart in "It's a Wonderful Life". Who knows? Maybe if you had your own personal angel take you back in time to what would've happened if you didn't listen, she may have had a very different outcome.

I have posted some of this personal stuff lately and am questioning whether or not it is wise to do so, even if I am saying positive things about professionals. Can doing that come back to haunt me? Thinking of pulling stuff and still trying to determine my blogging boundaries. :)

i think having a surgeon that listens like you did is amazing. I have run across a few who just talk over you and don't really "listen" like they are the last word. Havinga doc that listens can make a world of difference.

Dr. Schwab,This was your closest post I could find to my request...I'm studying stem cells in my A&P class now. If the immune system is triggered to attack foreign cells, I wondered if stem cell transplant is in vain in your opinion? Also the idea of potentially useful stem cells in the umbilical chord seems intriguing. Thank you for any thoughts on this subject.

Justine: as with any heterologous transplant, anti-rejection drugs would be needed in most instances (that might not be true in the brain, where they've been used experimentally to treat Parkinson's disease. Blood-brain barrier?) Autologous stem cells are commonly harvested prior to some forms of aggressive cancer therapy, and then re-infused into the patient after treatment, to repopulate the marrow. As to cord blood: it seems a promising area. As you may know, there are some people promoting the routine taking of it at birth, and preserving it for possible future needs of that child.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.